New Patient Form

New Patient Form

Health History Questionnaire
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Referred By

First NameLast Name
In case of emergency, we should notify:
Other Healthcare Professional
e.g. Occupational Therapist, Dietician, Naturopath, Chiropractor
Your safety and optimal oral health are our priorities. The following information enables us to provide you with the best oral health care services safely and effectively. Please complete the entire form. During you visit you will be asked questions regarding your questionnaire responses. All information is confidential and treated in accordance with applicable provincial and federal privacy legislation.

A. Dental Information

Rows	YES	NO
Do your gums bleed when you brush?
Do you regularly use fluoride products?
Have you ever had orthodontic or orthotropic treatment i.e. braces)?
Have you had any periodontal gum treatment?
Are your teeth sensitive to hot, cold, sweets or pressure?
Have you ever had an injury to your head, face or jaws?
Do you suffer from frequent headaches?
Do you have earaches or neck pains?
Do you have removable dental appliances?
Are you nervous during dental treatment?

Date of last dental examination:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of last dental x-rays

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please explain any YES answers:

B. General Information

Rows	YES	NO
Are you being treated for any change in your medical condition or have you been treated within the past year?
Has there been any change in your general health in the past year?
Have you ever been hospitalized for any illnesses or operations?
Do you have prosthetic or artificial joint (e.g. hip, knee)?
Have you ever been advised to take antibiotics before dental treatment?
Have you ever had a peculiar or adverse reaction including allergies to any medications or injections?
Do you have any allergies to any foods or materials (e.g. latex or metals)?
Do you have any other allergies (e.g. hay fever, animals)?
Cancer?
Dry Mouth?
Ear or hearing problems?
Eye problems (e.g. require corrective lenses, Glaucoma)?
Sleep disorders?
Are you or could you be pregnant?
Are you breastfeeding?
Are you taking hormone replacement therapy?

When was your last medical checkup?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please explain any YES answers:
Are you taking medications of any kind? Include prescription drugs over-the -counter medications (e.g. cold and flu remedy), and natural healthproducts (e.g. vitamins, herbal, and diet supplements). If yes, please list:
Drug Name/Amount, Dose, Frequency/Reason/Date Prescribed, Prescriber

C. Cardio/Respiratory

Rows	YES	NO
Chest pains upon exertion?
Shortness of breath?
Asthma?
Chronic bronchitis or emphysema?
Sinus trouble or nasal congestion?
Tuberculosis?
A persistent cough for more than 3 weeks?
Cough that produces blood?

D. Endocrine/Digestive

Rows	YES	NO
Malnutrition?
Eating disorder?
Dietary restrictions (self-imposed or doctor prescribed)?
Night sweats?
Slow healing or recurrent infections?
Thyroid or parathyroid disease?
A persistent cough for more than 3 weeks?
Cough that produces blood?

E. Gasterointestinal/Genitourinary

Rows	YES	NO
Hepatitis, jaundice, or liver disease?
Difficulty swallowing?
G.E. reflux/persistent heartburn?
A stomach ulcer?
Gall bladder problems?
Kidney or bladder trouble?
Excessive urination?

F. Hematologic

Rows	YES	NO
Prolonged or abnormal bleeding with a simple cut or following surgery, extraction, or an accident?
A blood transfusion?
A tendency to bruise easily?
Any blood disorder (e.g., anemia or hemophilia)?

G. Immune System/Infectious Diseases

Rows	YES	NO
Systemic lupus erythematosus?
Painful swollen joints or rheumatoid arthritis?
HIV/AIDS?
Other diseases or conditions that affect your immune system (e.g., sarcoidosis, Epstein-Barr, radiotherapy, chemotherapy, steroid therapy)?
Sexually transmitted diseases (e.g., herpes)?
Have you ever had an antibiotic resistant infection (e.g., MRSA)?

H. Neurological/Musculoskeletal

Rows	YES	NO
A stroke?
Convulsions or seizures (e.g., epilepsy)?
Mental health disorders?
Arthritis?
Osteoporosis or osteopenia?
Chronic pain?

I. Other

Rows	YES	NO
Do you have a drug or alcohol dependency?
Other diseases or medical problems that run in your family?
Other conditions or medical problems not listed?
Other special needs that will affect your dental care?